Provider Demographics
NPI:1043834278
Name:ROBERTS, CHARLES EUGENE IV
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:EUGENE
Last Name:ROBERTS
Suffix:IV
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:547 E COLUMBUS AVE
Mailing Address - Street 2:
Mailing Address - City:BELLEFONTAINE
Mailing Address - State:OH
Mailing Address - Zip Code:43311-2480
Mailing Address - Country:US
Mailing Address - Phone:937-210-6818
Mailing Address - Fax:
Practice Address - Street 1:547 E COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:BELLEFONTAINE
Practice Address - State:OH
Practice Address - Zip Code:43311-2480
Practice Address - Country:US
Practice Address - Phone:937-210-6818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-03
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH000870175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist